PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE

PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE

COMPLETE SECTION I ONLY. PRINT CLEARLY IN INK. ENCLOSE $10.00 MONEY ORDER ONLY. PAYABLE TO DEPARTMENT OF PUBLIC WELFARE. DO NOT SEND CASH OR PERSONAL CHECK.

SEND TO CHILDLINE AND ABUSE REGISTRY, DEPARTMENT OF PUBLIC WELFARE, P.O. BOX 8170 HARRISBURG, PA 17105-8170

APPLICATIONS THAT ARE INCOMPLETE ILLEGIBLE OR RECEIVED WITHOUT FEE WILL BE RETURNED UNPROCESSED. IF YOU HAVE QUESTIONS CALL 717-783-6211

CHILDLINE USE ONLY

DATE RECEIVED BY CHILDLINE

SECTION I

APPLICANT IDENTIFICATION

IN THIS SPACE PRINT APPLICANTS FULL NAME AND ADDRESS (DO NOT USE INITIALS)

NAME

SOCIAL SECURITY NUMBER

STREET

CITY, STATE ZIP CODE

AGE

DATE OF BIRTH

SEX M

COUNTY YOU LIVE IN F

DAYTIME PHONE NO.

(FIRST, MIDDLE, LAST)

PREVIOUS NAMES USED SINCE 1975 (Include Maiden Name, Nicknames, Aliases)

(FIRST, MIDDLE, LAST)

PURPOSE OF CLEARANCE (Check ONE block ONLY)

CHILD CARE FOSTER CARE ADOPTION SCHOOL

VOLUNTEERS-A copy of your PROCESSED 'Request

for Criminal Record'' (Form SP4-164) must be attached. Out-of-state residents must also attach a copy of their PROCESSED FBI clearance (Form FID-258).

CWEP (Community Work Experience Program Participant)

SIGNATURE OF CAO REP

CAO PHONE NO

PREVIOUS ADDRESSES SINCE 1975 (Attach additional pages if necessary)

1.

2.

3.

4.

HOUSEHOLD MEMBERS (List everyone who lived with you at anytime since 1975 to the present).

NAME (First, Middle, Last) Do not use initials.

RELATIONSHIP

PRESENT

AGE

SEX

1.

2.

3.

4.

5.

6.

I certify that the above information is accurate and complete to the best of my knowledge and belief and submitted as true and correct under penalty of law (Section 4904 of the Pennsylvania Crimes Code).

Applicants are required to show the Administrator the original

document. Administrators are required to keep a copy of this

child abuse history record on file. Any person altering the

contents of this document may be subject to civil, criminal or

administrative action.

APPLICANT'S SIGNATURE

DATE

SECTION II

DO NOT WRITE IN THIS SECTION - CHILDLINE USE ONLY

RESULTS OF HISTORY CHECK

APPLICANT IS NOT LISTED IN A REPORT OF CHILD ABUSE OR A REPORT FOR SCHOOL EMPLOYEE.

STATUS OF REPORT 1.

DATE OF INCIDENT

2.

APPLICANT IS LISTED IN A REPORT OF CHILD ABUSE OR A REPORT FOR SCHOOL EMPLOYEE (SEE BELOW).

STATUS OF REPORT 3.

DATE OF INCIDENT

4.

03460C

VERIFIER

DATE

VERIFIER'S SUPERVISOR

DATE

CY 113

12/99

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SECTION III

DO NOT WRITE IN THIS SECTION - CHILDLINE USE ONLY VOLUNTARY CERTIFICATION FOR CHILD CARE SERVICES

has requested a certification which includes a clearance of his/her name against the child abuse, school employee, and criminal history reports.

The results of the child abuse and school employee report clearances are listed in Section II on the reverse side. The results of the criminal history reports are listed below. Out-of-state residents must have criminal history clearance from both the Pennsylvania State Police and the FBI. The voluntary certification may be obtained every two years.

It is the responsibility of parents and guardians to review this information to determine the suitability of the applicant as a substitute caregiver.

PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE Applicant is named as the perpetrator of a ''Founded'' child abuse or school employee report which occurred in the last five years.

Applicant is named as the perpetrator of a ''Founded'' child abuse or school employee report which occurred over five years ago.

Applicant is named as the perpetrator of an ''Indicated'' child abuse or school employee report.

Applicant is not named as the perpetrator of any child abuse or school employee report contained in the Statewide Central Register.

PENNSYLVANIA STATE POLICE CLEARANCE

Record exists and contains convictions which prohibit hire in a child care position. Report attached.

Record exists, but convictions do not prohibit hire in a child care position. Report attached.

Record exists, but no convictions are shown. This does not prohibit hire in a child care position. Report attached.

No record exists. Report attached.

FBI CLEARANCE Record exists and contains convictions which prohibit hire in a child care position. Report attached. Record exists, but convictions do not prohibit hire in a child care position. Report attached.

Record exists, but no convictions are shown. This may not prohibit hire in a child care position. Report attached. No record exists. Report attached.

No FBI clearance required.

034600

VERIFIER

DATE

VERIFIER'S SUPERVISOR

DATE CY 113 - 12/99

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